West Virginia State Board of Barbers and Cosmetologists

1201 Dunbar Avenue

Dunbar, West Virginia 25064
Tel: 304.558.2924 Fax: 304.558.3450
www.wvbbc.com

WORK PERMIT APPLICATION

*APPLICANT NOTICE: This is an application for an individual to obtain a work permit that graduated from a school of barbering,
cosmetology, or other cosmetology-related services in West Virginia or in another state. Students must have completed their full course of
study and be scheduled for the examinations through the Board's testing administrator. This application must be signed by the student and
the school owner/manager. If you graduated from a school in another state, you must include the following information with
this application: Copy of Government-issued photo ID; Copy of Social Security Card; Official Transcripts; Copy of High School diploma,
GED, or ATB results; and Completed Certificate of Health form. If you hold a valid license or other authorization to practice in another state,
please apply for licensure by submitting the Application for Registration by Reciprocity. Incomplete applications will be returned.

Please make sure: Please check the box below. I affirm that all
information within this
All fields are completed This is the first time registered for the exam. document true and
accurate by proof of
$15.00 permit fee is enclosed This is the second time registered for the exam. signatures on this
All signature fields are signed I have registered for this exam more than three times. application.

APPLICANT INFORMATION To be completed by the applicant receiving the work permit.

NAME SSN #

FULL ADDRESS

PHONE # EMAIL

APPLICANT SIGNATURE DATE

SCHOOL INFORMATION To be completed by the school owner or manager.

NAME OF SCHOOL OWNER/MANAGER

DATE GRADUATED HOURS EARNED DATE SCHEDULED FOR EXAM

By my signature below, I affirm on behalf of the name and school above that the information is true and accurate.

SCHOOL OWNER/MANAGER DATE

NOTARY SIGNATURE
The above information and signatures are true to the best of my knowledge. Stamp Here

Notary's Name County Of

State Of

Sworn and subscribed to me on: Date: Signed By

This form contains Personally Identifiable Information (PII). The SSN number collected within this form is to manage your license account by effectively identifying your
information and will not be shared with a third-party. The information collected on this form will be securely protected through the Board's server database. By submitting
this form, I agree to the policy.

Revised: August 31, 2020